Welcome to CPD

2nd Part

Dr. Md. Kamrul Hasan

FCPS Part-II Trainee,Paediatrics
ICMH
16-10-2022
Pleural Effusion : An Overview
 Introduction

• Pleural effusion means presence of excess fluid

between the two pleural membranes (visceral & parietal)
that envelop the lungs

• The term "effusion" comes from the Latin " effusio"

meaning a pouring out

• A pleural effusion is thus, literally, a pouring out of fluid

into the pleural space
 Introduction (Cont….)

• Normally a small quantity (15-20 ml) fluid spreads thinly

over visceral & parietal pleurae, serving as a lubricant

• But alteration of flow/poor absorption leads to

fluid accumulation in the pleural space

• Early in the course, the pleura becomes inflamed;

subsequent leakage of proteins, fluid along with
leukocytes into the pleural space forms the effusion
Pleural Effusion
 Epidemiology

• Prevalence of pleural effusion is 320/100,000 people in

industrial countries
• ICMH data total 45 patient From 1st January 22-31st
August, 23
• Among them pleural tap was done on 18 patients. 8
patients were diagnosed as PTB, 12 patients were para
pneumonic effusion and 2 patients were diagnosed as
malignancy.
• Male-Female ratio is equal, although certain
etiologies have sex predilection.
 Pathophysiology

• The primary cause of a pleural effusion is

simply an imbalance between the fluid
production and removal in the pleural space
• Normally approximately 15-20 ml of fluid /day
enters this potential space from the capillaries
and removed by the lymphatics in the parietal
pleura.
• This regulated fluid balance is disrupted when
local or systemic derangements occur.
Pathophysiology (Cont.….)

• Local factors include leaky capillaries from

inflammation due to infection, infarction or
tumour
• Systemic factors include elevated pulmonary
capillary pressure with heart failure, excess
ascites with cirrhosis, or low oncotic pressure
due to hypoalbuminaemia (e.g. with nephrotic
syndrome)
Different mechanisms of pleural effusion

•  capillary hydrostatic pressure - CCF

•  pleural space hydrostatic pressure - Atelectasis
•  plasma oncotic pressure - NS
•  capillary permeability - infection, connective tissue
disease, malignancy
• Impaired lymphatic drainage - disruption of thoracic
duct flow
• Passage of fluid from the peritoneal cavity through the
diaphragm to the pleural space - cirrhosis of liver
Types of pleural effusion
From the pathological view there are 2 types:
• Transudative pleural effusion:
It is caused by either an increased hydrostatic
pressure within the pleural capillaries or a
decreased colloid osmotic pressure in the
circulatory system. Pleural fluid proteins <3 gm/dL

• Exudative pleural effusion:

It is caused by increased capillary permeability
resulting from inflammatory process related to
infections or malignancies. Pleural fluid proteins
>3gm/dL
 Etiology (cont....)

Transudative pleural effusion

(usually bilateral)

Very common causes are

• Heart failure
• Liver cirrhosis
 Etiology (cont....)

Less common causes are:

• Hypoalbuminaemia
• Nephrotic syndrome
• Peritoneal dialysis
• Hypothyroidism/Myxedema
• Mitral stenosis
• Constrictive pericarditis
• Urino-thorax (due to obstructive uropathy) etc
 Etiology (cont....)

Exudative pleural effusion (uni or bilateral)

Common causes are
• Pneumonic effusions
• Tuberculosis
• Malignancy (lung or breast, lymphoma,
leukemia; less commonly, ovarian carcinoma,
stomach, sarcomas, melanoma, mesothelioma)
• Pulmonary embolism
• Collagen-vascular conditions (rheumatoid &
systemic lupus erythematosus)
Etiology (cont....)

Less common causes are

• Asbestosis
• Pancreatitis
• Post-myocardial infarction; Post-CABG Pericardial
disease
• Meigs syndrome (pelvic neoplasm with
ascites/effusion)
• Ovarian hyper-stimulation syndrome
• Yellow nail syndrome (yellow nail, lymphedema,
effusion)
• Chylothorax (acute illness with elevated triglycerides in
pleural fluid) etc
 Clinical presentation

History:
• Risk of effusion: Infection, malignancy, NS,
heart failure etc
• Drug history
• Recent trauma/thoracic surgery
• History of chronic hepatitis
• Asbestos exposure (home/work)
• An occupational history and Alcoholism in adults
 Clinical presentation (cont...)
Pulmonary Symptoms
• Asymptomatic
• Breathlessness (progressive dyspnoea)
• Cough (mild and nonproductive)
• Pleuritic chest pain
- Pain may be mild or severe. It is more typically described as
sharp/stabbing and exacerbated with deep inspiration
 Clinical presentation (cont...)
Extra pulmonary symptoms
May suggest the underlying disease process
Leg edema, orthopnea, paroxysmal nocturnal
dyspnoea in heart failure
Acute febrile episode, purulent sputum, pleuritic
chest pain is found in pneumonia
Prolong fever, night sweat, hemoptysis and weight
loss should suggest TB
Hemoptysis is seen in malignancy, pulmonary
infraction, other endotracheal or endobronchial
pathology
 Physical examination
Physical findings in pleural effusion varies
depending on volume of effusion:
Inspection:
1) Fullness of the intercostal spaces
2) Tachypnea
3) Decreased thoracic wall movement
Palpation:
1) Trachea and apex shifted to contra-lateral
side
2) Decreased thoracic wall expansion
3) Decreased vocal fremitus
Physical examination(cont...)
Percussion:
1) Dull on percussion ( Stony dull)
Auscultation:
1) Breath sounds diminished or
absent
2) Vocal resonance diminished or
absent
3) Pleural rub found during early
phase
 Physical examination(cont...)
Other extra pulmonary findings may suggest the
underling cause of effusion:
• Peripheral edema, distended neck vein and
gallop rhythm is suggestive of CHF
• Edema also manifests NS or pericardial disease
• Cutaneous change and ascites is suggestive of
liver disease
• Lymphadenopathy or palpable mass may
suggest malignancy
• Edema when combined with yellow nail beds
indicates the yellow nail syndrome.
Investigations

• Chest X-Ray
• Chest Ultrasound
• CT scan
• Pleural fluid aspiration study
• Pleural biopsy
• Thoracoscopy/VAT (video assisted thoracoscopy)
• Bronchoscopy
 Imaging: Chest radiograph
• Homogenous opacities
obliterating the markings of
the underlying lung fields
• Crescentic upper margin
of fluid
• Obliteration of
costophrenic and
cardiophrenic angles
• Shifting of mediastinum
to opposite side in huge
collection
Huge Pleural effusion-left
Imaging: Chest radiograph

Upright position films

• A/P projection can see 300 ml
• Lateral projection can see 200 ml

Lateral decubitus films

• Can check for free-flowing pleural fluid
• Can see as little as 50 ml of fluid
 Imaging - USG

Ultrasound

• Can diagnose small (3-5

ml) loculated collection of
fluid
• Useful as a guide for
thoracocentesis
• Can distinguish between
pleural thickening and
pleural effusion
 Imaging- CT scan
CT scan
• Defines empyema, abscess,
malignancy, bronchopleural
fistula etc
• Useful for defining extent of
loculated effusion
Diagnostic Thoracocentesis
 Pleural fluid study

Normal Color : Straw (yellow)

• Serous in Pneumonia
• Amber colored in TB
• Serous Straw colored in Cardiac Failure
• Serous turbid in Rheumatoid Disease
• Seroud blood stained in Malignancies.
 Pleural fluid study(cont...)

• Frankly purulent fluid indicates an empyema

• A milky fluid suggests a chylothorax (lymphatic obstruction)
• Grossly bloody fluid
• Trauma
• Malignancy
• Asbestosis
Pleural fluid study(cont...)
Biochemical study (5ml; we need to
send serum sample at the same time)
• PH : 7.60-7.64
• Protein content: <1.5 g/dl
• Cell count: <1000 white blood cells/cmm
• Glucose content similar to that of plasma
• Lactate dehydrogenase (LDH): <50% of
plasma
 Pleural fluid- cell count
• Neutrophils are associated with acute
processes, e.g. pneumonic effusions,
pulmonary embolism, acute TB and
asbestosis
• >85% fluid lymphocytosis suggests -TB,
lymphoma, sarcoidosis, rheumatoid arthritis,
yellow nail syndrome or Chylothorax
• 50-70% fluid lymphocyte suggests
malignancy
Pleural fluid - glucose

A low pleural glucose (30-50 mg/dl) suggests

1. Malignant effusion
2. Tuberculous pleuritis
3. Lupus pleuritis
4. A very low pleural glucose (i.e. <30 mg/dl)
suggest rheumatoid pleurisy or empyema
 Pleural fluid analysis
Test Transudate Exudate
pH 7.4 < 7.3
Protein (g/dl) < 3.0 > 3.0
LDH (IU/ml) < 200 > 200
Pleural/ serum <1 >1
amylase ratio
Glucose (mg/dl) > 40 < 40
RBC < 5000 > 5000
WBC <1000(Mostly monocyte) >1000(mostly polymorph)
Cholesterol <45 >45
(mg/dl)
Pleural fluid analysis(cont...)
Light’s criteria:
A pleural effusion is likely to be
exudative if at least one of the following
exists -
1. Pleural fluid/serum ratio of protein is >0.5
2. Pleural fluid/serum ratio of LDH is >0.6
3. Pleural fluid LDH is greater than 0.6 times
or 2/3rd times the normal upper limit for
serum
Lab work up

• Usual sample for microbiological tests : not

less than 20 ml
• We ask for
Gram staining
Culture and sensitivity
AFB staining and culture for TB bacilli
GeneXpert/PCR for TB
Other Lab work up

• Pleural fluid adenosine deaminase (ADA): >43 u/ml in TB

• Interferon-gamma level: >140 pg/ml in TB
• Ask to look for malignant cells
• Also ask for cell block (pleural clot)
 Thoracocentesis-
Contraindication
• Absolute contraindications
None
• Relative contraindications
1. Bleeding disorder or anticoagulation
2. Uncertain fluid location
3. Minimal fluid volume
4. Altered chest wall anatomy
Thoracocentesis : Contraindication

5. Cellulitis or herpes zoster at the site of thoracentesis

puncture
6. Pulmonary disease severe enough to make
complications life threatening
7.Uncontrolled coughing or an uncooperative patient
Thoracocentesis : Complication

• Pain at the puncture site

• Bleeding
• Pneumothorax
• Empyema
• Spleen/liver puncture
• Re-expansion pulmonary oedema
Pleural biopsy

• Done if thoracocentesis is not diagnostic

• Most useful for diseases that cause extensive involvement of
the pleura (TB, malignancies)
• Confirms neoplastic involvement in 40-70% of cases
 Management

A) Counseling:
Counseling about the nature and future of
the problem, good outcome with drainage and
medication.
B) Symptomatic/supportive treatment:
• Antipyretic for fever
• O2 inhalation for hypoxia
• Fluid and nutrition maintenance
• Antitussive and bronchodilator (if necessary)
• Theraputic aspiration of pleural fluid.
Management(cont...)

C) Specific/as per disease:

• Antibiotics/ Anti-TB/ Chemotherapy
• Intercostal chest tube drainage
• Decortication/Pleurectomy
• Pleurodesis etc
Management(cont...)

•Parapneumonic Pleural effusion-

1. Aspiration is required to prevent empayema & pleural thickening
2. Appropriate Antibiotic
•Tubercular pleural effusion:
1. Anti TB drug according to Catagory 2
 Treatment Regimens for Children in Each TB
diagnostic category
TB Regimen
Smear negative pulmonary TB (without Intensive Continuati
extensive involvement) phase on phase
TB lymph node (intrathoracic/extrathoracic) 2(HRZ) 4(HR)
Smear positive pulmonary TB
Smear negative PTB with extensive
involvement 2(HRZ)E 4(HR)
Severe EPTB (except TBM and
Osteoarticular)
Previously treated cases
All forms of TB in HIV +ve cases (except TBM
and osteoarticular)
TB meningitis/CNS TB 2(HRZ)E 10(HR)
Osteoarticular TB
MDR TB Specially designed
XDR TB standardized treatment
 Chest tube drainage
Indication of chest tube drainage in Pleural effusion
1. Absolute-
• Purulent pleural fluid
• Repeated accumulation of sufficient amount of fluid
1. Relative –
• Pleural fluid pH below 7.20
• Pleural fluid pH below 50 mg/dl
 Pleurodesis

• Also known as pleural sclerosis

• Done by instilling an irritant into the
pleural space to cause inflammatory
changes that result in bridging fibrosis
between the visceral and parietal pleural
surfaces Causing obliteration of pleural space
by extensive adhesion.
• Sclerosing agents are -Talc, doxycycline,
Tetracycline, keoline, bleomycin etc
Surgical Management
• Video-assisted thoracoscopy and drainage of loculated pleural
fluid
• Surgically implanted pleuro-peritoneal shunts
Complications of pleural
effusion
• Lung scaring/ fibrosis
• Pneumothorax
• Collapse
• Sepsis
• Empyema
• Bronchopleural fistula
Discharge/Follow up

• A discharge summary must be produced

with a copy of the last Chest X-Ray.
• Antibiotics/anti-TB should be given with
appropriate dose and duration.
• Counseling to the parents need to be done.
• Advice for follow-up should be given
approximately 2 weeks after discharge.
 Prognosis

• Depends on underlying condition and early initiation of treatment.

• Most cases of pleural effusion have no long term sequelae.
• Recurrence rate is more if pleural effusion is due to heart failure,
cirrhosis or malignancy.
• Prognosis is poor in malignant pleural effusion.
Thank You
All